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<!DOCTYPE html>
<html>
    <head>
        <title>Agregar Pago</title>
        <meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
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    <!-- <script src="../global/bootstrap/js/bootstrap-dropdown.js"></script>-->
    <!-- BEGIN bloque_javascript -->
            <script src="{javascript}"></script>
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    </head>
    <body>
     

             <div class="row" style="padding-left:30px;">
                 <h1>Tarjeta Rosada </h1> 
           <div style="float:left;margin-right:1px;">
               <form action="{accion}" method="POST" class="well span14">

                   <div class="row " style="padding-left:40px;margin-top:2px;">
                       
                       <div class="alert alert-info"><strong>Nota:</strong> Todos los campos son obligatorios</div>
                      <label style="float:left;margin-right:10px;padding-top:4px;">Apellido/s</label> 
                      <div style="float:left;margin-right:20px;">
                        <input type="text" style="width:180px;" name="apellido" id="apellido" value="{apellido}">
                      </div>
                      <label style="float:left;margin-right:10px;padding-top:4px;">Nombre/s</label> 
                      <div style="float:left;margin-right:20px;">
                        <input type="text" style="width:200px;" name="nombre" id="nombre"  value="{nombre}">
                      </div>
                      
                      
                      <script type="text/javascript">
                        window.onload = function(){
                                new JsDatePick({
                                        useMode:2,
                                        target:"fecha_nac",
                                        dateFormat:"%d-%m-%Y"

                                });
                            };
                      </script>
                      
                      <label style="float:left;margin-right:10px;padding-top:4px;">Fecha de nacimiento</label> 
                      <div style="float:left;margin-right:20px;">
                        <div style="float:left">
                         <input type="text"  style="width:80px;" name="fecha_nac" id="fecha_nac" value="{fecha_nac}">
                        </div>
                      </div>
                      
                      
                     </div> 
                   
                   <div class="row " style="padding-left:40px;margin-top:2px;">
                        <label style="float:left;margin-right:10px;padding-top:4px;">Tipo de documento</label> 
                      <div style="float:left;margin-right:20px;" id="tipo_documento">
                        <select style="width:138px;" name="tipo_documento" id="tipo_documento" >
                            <option value="0">Seleccione un tipo de documento</option>
                            <!-- BEGIN tipo_docs -->
                            <option value="{id_tipo_doc}" {tipodoc_selected}>{tipo_doc}</option>
                            <!-- END tipo_docs -->
                        </select>
                      </div> 
                    
                      
                      <label style="float:left;margin-right:10px;padding-top:4px;">N&uacute;mero de documento</label> 
                      <div style="float:left;margin-right:20px;">
                        <input type="text" style="width:150px;" name="nro_doc" id="nro_doc"  value="{nro_doc}">
                      </div>

                      
                      <label style="float:left;margin-right:10px;padding-top:4px;">CUIL</label> 
                        <div style="float:left;margin-right:20px;">
                            <div style="float:left">
                            <input type="text"  style="width:150px;" name="cuil" id="cuil" value="{cuil}">
                            </div>
                        </div>
                      
                      
                    </div>
                   
                   
                   <div class="row" style="padding-left:40px;">

                      <label style="float:left;margin-right:10px;padding-top:4px;">Domicilio</label> 
                      <div style="float:left;margin-right:20px;">
                        <input type="text"  style="width:170px;" name="domicilio" id="domicilio" value="{domicilio}">
                      </div>
                      
                      <div class="row" style="padding-left:40px;">
                        <label style="float:left;margin-right:10px;padding-top:4px;">Provincia</label> 
                      <div style="float:left;margin-right:20px;">
                        <select style="width:150px;" name="provincia" id="provincia" onchange="seleccionar_ciudad(this);">
                            <option value="0">Provincia</option>
                            <!-- BEGIN blq_provincias -->
                            <option value="{provincia_id}" {selected_provincia} >{provincia_nombre}</option>
                            <!-- END blq_provincias -->
                        </select>
                      </div> 
                         <label style="float:left;margin-right:10px;padding-top:4px;">Ciudad</label> 
                      <div style="float:left;margin-right:20px;" id="select_ciudades">
                        <select style="width:150px;" name="ciudad" id="ciudad" >
                            <option id="primera_ciudad" value="0">Provincia</option>
                           <!-- BEGIN blq_ciudades -->
                            <option value="{ciudad_id}" {selected_ciudad} >{ciudad_nombre}</option>
                            <!-- END blq_ciudades -->
                        </select>
                      </div> 
                         
                           <label style="float:left;margin-right:10px;padding-top:4px;">CP</label> 
                            <div style="float:left;margin-right:20px;">
                                <input type="text"  style="width:40px;" name="cp" id="cp" value="{cp}">
                            </div> 
                    </div>
                      
                      
		    </div>
                   
                    <div class="clearfix">
                        <input type="submit" value="Guardar" class="btn btn-primary ">
                    </div>
                    <input type="hidden"  name="id" id="id" value="{id}">
                    <input type="hidden"  name="venta" id="venta" value="{venta}">
                      <input type="hidden"  name="acc" id="acc" value="{acc}">
                   <!-- BEGIN error_msg -->
                      <div class="alert alert-error">
                        {mensaje_error}
                      </div>
                  <!-- END error_msg -->
                  <!-- BEGIN exito_msg -->
                      <div class="alert alert-success">
                        {mensaje_exito}
                      </div>
                  <!-- END exito_msg -->

               </form>
           </div>   
       </div>
        
        
        <!-- BEGIN blq-nores -->
        <div class="row alert alert-heading span10" >{alerta_info}</div>
         <!-- END blq-nores -->
         
             </body>
</html>